40000309 - MassHealth Field Auditing TaskforceData Current as of: 7/7/2012

MassHealth Field Auditing Taskforce For the expansion of auditing activities in MassHealth including, but not limited to, field audits of high risk services; provided, that no expenditures shall be made from this item that are not federally reimbursable; provided further, that notwithstanding any general or special law to the contrary, the state Medicaid office may conduct a trial to determine the effectiveness of various fraud management tools to identify potential fraud at claims submission and validation in order to reduce Medicaid fraud prior to payment; provided further, that the state Medicaid office may employ strategies to improve systems for detection and may allow for the use of external data sources; provided further, that any such trial may test innovative technologies to improve Medicaid fraud detection and evaluate the efficacy of a real-time model to identify and investigate potential Medicaid fraud cases prior to payment and other innovations; provided further, that the Medicaid office may use actual claims data, in accordance with federal law, to identify specific suspicious provider billing patterns, document the results of any potential fraud findings and estimate anticipated savings and benefits to the commonwealth associated with such a fraud detection system; provided further, that the executive office shall report to the house and senate committees on ways and means not later than January 18, 2013 detailing total audit findings and recoveries in fiscal year 2012 and estimated recoveries in fiscal year 2013; provided further, that the report shall differentiate audit findings and recoveries by investment or program as well as by line item; provided further, that the report shall also identify any audits and recoveries referred by the office of the state auditor; provided further, that the executive office shall report to the house and senate committees on ways and means not later than April 1, 2013 on prepayment audit efforts; and provided further, that the report shall include and be limited to: (i) the original amount of estimated payments prior to prepayment audit; (ii) the actual amount of payments made following prepayment audits